Recurring concern

Failure to recognise impaired decision-making capacity in care decisions

First to latest report 16 Dec 2013 — 10 Mar 2026

Reports that mention this concern
37
Times this concern has been raised
39
Stated actions linked to this concern
101

What this concern includes

Includes failures to recognise, assess or account for impaired cognition or probable lack of decision-making capacity in decisions about a person’s care and welfare, including when capacity is wrongly inferred from acquiescence.

What is not included
  • Excludes failures concerning other patient characteristics or risks unless they directly concern recognition or assessment of decision-making capacity.
  • Excludes failures in best-interest decision-making that omit carers’ or social services’ views when no capacity-recognition failure is identified.
  • Excludes generic documentation, communication or care-planning deficiencies that are not specifically tied to impaired decision-making capacity.

Reports and published responses 37 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Manchester City

    AI-generated summary

    Name not published · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    A 79-year-old woman was admitted to hospital on 15 March 2015 with hypothermia, reduced responsiveness and reduced mobility. She developed pneumonia, sepsis and acute respiratory distress syndrome, and died on 23 March 2015. The principal concerns were failures in investigations and handover, mental-capacity assessment, monitoring and escalation of deterioration, and staffing competence and seniority.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to assess mental capacity during admission and transfer

    Wider context from the report

    “1. Mental Capacity. There was no apparent consideration to the issue of whether or not the deceased had mental capacity from admission to A & E and transfer to AMU. ”

    Source location

    Name not published · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report

  2. Brighton and Hove

    AI-generated summary

    Derek LEE · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Derek LEE died on 5 June 2016 following an admission to Brunswick Ward. The report identified numerous concerns about his care, including medication management, incomplete assessments and documentation, falls and pressure-sore prevention, delayed referrals and treatment, nutrition, mobility, and the absence of a care co-ordinator. The inquest concluded that the death was from natural causes, and the report stated that the identified failings did not change the outcome.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to properly assess mental capacity

    Wider context from the report

    “(2) Re: Admission Documentation – Mental capacity was not properly assessed and when Mr Lee was discharged from the ward after three weeks on the 17th May the paperwork in that respect was still incomplete. ”

    Source location

    Derek LEE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Cheshire

    AI-generated summary

    Brian Gerrard · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Brian Gerrard had moderately severe mixed Alzheimer’s/vascular dementia, depression and intermittent infections, and died after becoming undernourished because he was not eating sufficiently. The inquest concluded that he died from natural causes, namely lack of eating due to dementia. Concerns related to staff understanding and management of best-interests meetings, identification of lack of capacity, and implementation of Deprivation of Liberty Safeguarding procedures, including inaccurate and contradictory information in an application.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to identify lack of capacity

    Wider context from the report

    “The MATTERS OF CONCERN relate to (1) the understanding of staff in relation to the proper management of a best interests meeting, (2) the identification of lack of capacity and (3) the implementation of Deprivation of Liberty Safeguarding procedures. All such deficiencies appeared to warrant an amendment of procedures and a requirement for appropriate training. On 26th September 2014 a best interests, multidisciplinary meeting was called at your hospital to decide upon what action to take to address the fact that the deceased was not eating sufficiently and might be close to death. Those present at the meeting included the deceased’s named nurse who took the minutes of the meeting, the deceased’s wife, a psychiatrist who was the deceased’s responsible clinician and a General Practitioner from the deceased’s medical practice. The meeting decided that it was in the deceased’s best interests to remain at your hospital rather than being transferred to a general hospital for treatment. In that regard the minute of the meeting correctly reflected what had been agreed. However, it was also minuted that the deceased had determined to die and that to achieve this aim he was deliberately not eating and that he had capacity to make such a decision. Such did not represent the opinion of the psychiatrist / responsible clinician nor the opinion of the general practitioner, both of whom were of the view that the deceased did not have capacity and that he had not formulated a plan to die but that his lack of eating was a product of his illness. Thereafter an application for a Deprivation of Liberty Safeguard contained inaccurate and contradictory information and appeared to demonstrate a lack of familiarity with procedures. For instance, the application asserted that the deceased had capacity to make decisions with regard to his care needs when such did not represent the opinions of the clinicians responsible for the deceased’s care. ”

    Source location

    Brian Gerrard · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  4. Manchester City

    AI-generated summary

    Leslie Johnson · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Leslie Johnson, who required supported care and had a swallowing assessment recommending a soft diet and supervision, died in hospital after being left unsupervised while eating an egg mayonnaise sandwich. A post-mortem examination found that he died from acute aspiration of food. Concerns included failures to assess or recognise his lack of mental capacity and failures to communicate his care plan and swallowing requirements between community carers and the hospital.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to formally assess and recognise mental capacity on hospital admission

    Wider context from the report

    “2. Consequently, upon his admission to hospital, it was not recognised that he lacked mental capacity. There was no formal assessment and he was treated as an ordinary patient. ”

    Source location

    Leslie Johnson · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Continue implementing frailty and delirium screening tools, including a unified tool across Trafford and the central site.

    Verbatim wording from the response

    “The Trust is in the process of implementing a transformation project regarding a delirium tool and a frailty flag to help identify those patients who may have reduced capacity. The Trust are working with Patientrack, our partners for the electronic Early Warning Score system, to embed a frailty screen in patients aged over 75 which would then identify patients requiring a comprehensive geriatric assessment. The next stage would be to embed a delirium screen into Patientrack. This work continues to progress and currently a pilot of frailty screening, CGA and delirium screening is taking place at our Trafford site, from which the initial feedback is positive. This will then be developed to produce a unified tool across Trafford and central site and support the care provided to our vulnerable, frail and elderly population.”

    Source location

    MORRISON-Leslie-Response
    Page 3 · response
    Published 28 July 2016

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Provide monthly DoLS training on the process and completion of DoLS and mental capacity assessments.

    Verbatim wording from the response

    “With regards to staff training around mental capacity and DoLS, I can confirm that we have monthly DoLS training sessions in place regarding awareness of the process and the completion of DoLS and mental capacity assessments. In addition there have also been sessions arranged with our Solicitor partnership firm for external training sessions to be held.”

    Source location

    MORRISON-Leslie-Response
    Page 3 · response
    Published 28 July 2016

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Arrange external training sessions on mental capacity and DoLS with the Trust’s solicitor partnership firm.

    Verbatim wording from the response

    “With regards to staff training around mental capacity and DoLS, I can confirm that we have monthly DoLS training sessions in place regarding awareness of the process and the completion of DoLS and mental capacity assessments. In addition there have also been sessions arranged with our Solicitor partnership firm for external training sessions to be held.”

    Source location

    MORRISON-Leslie-Response
    Page 3 · response
    Published 28 July 2016

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Mandate level 3 Adult Safeguarding training for all registered nurses, covering DoLS and mental capacity.

    Verbatim wording from the response

    “In addition we also mandate within the Trust that all registered nurses complete level 3 Adult Safeguarding training, which is the most advanced safeguarding training we offer clinicians; DoLS and mental capacity is covered within the body of this training. The safeguarding team also offer bespoke sessions to areas who require further support or detail regarding the completion of DoLS.”

    Source location

    MORRISON-Leslie-Response
    Page 3 · response
    Published 28 July 2016

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Provide bespoke safeguarding sessions to areas needing additional support with completing DoLS and mental capacity assessments.

    Verbatim wording from the response

    “In addition we also mandate within the Trust that all registered nurses complete level 3 Adult Safeguarding training, which is the most advanced safeguarding training we offer clinicians; DoLS and mental capacity is covered within the body of this training. The safeguarding team also offer bespoke sessions to areas who require further support or detail regarding the completion of DoLS.”

    Source location

    MORRISON-Leslie-Response
    Page 3 · response
    Published 28 July 2016

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Consider including safeguarding, particularly DoLS and mental capacity, at quarterly Audit and Clinical Effectiveness Days and make implementation plans.

    Verbatim wording from the response

    “We are also considering the inclusion of safeguarding at each of our quarterly Audit and Clinical Effectiveness Days, focusing in particular on DoLS and mental capacity. This will be discussed further and plans for implementation made.”

    Source location

    MORRISON-Leslie-Response
    Page 3 · response
    Published 28 July 2016

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Discuss the coroner’s concerns at the Trust Clinical Effectiveness Committee to consider how to improve consideration of mental capacity assessments and DoLS authorisations.

    Verbatim wording from the response

    “Moving forward and in order to improve the consideration given to mental capacity assessments and DoLS authorisations, your letter will be discussed at the Trust Clinical Effectiveness Committee to note your concerns and consider how this should be addressed. Any further action will then be monitored via this committee and allocated to the relevant leads.”

    Source location

    MORRISON-Leslie-Response
    Page 3 · response
    Published 28 July 2016

    Open published response

  5. Nottinghamshire

    AI-generated summary

    Elsie Marjorie Brown · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Elsie Marjorie Brown fell from her bed at Langwith Lodge Residential Care Home on 23 March 2015, suffering fractures to her left humerus and right hip. She died in hospital on 5 April 2015 from bronchopneumonia and lobar pneumonia, which developed as a result of the fractures. Concerns included the absence of falls-risk and bed-rails assessments, an incomplete and unreviewed care plan, unclear responsibilities, inadequate recording and handovers, insufficient auditing, and potentially inadequate night staffing.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to assess mental capacity

    Wider context from the report

    “1. There was no falls risk assessment nor bed rails assessment in place for Mrs Brown, nor was her mental capacity assessed. ”

    Source location

    Elsie Marjorie Brown · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    A formal capacity assessment was not considered necessary because capacity was presumed unless evidence showed that Mrs Brown lacked capacity.

    Verbatim wording from the response

    “The Company also, since 2010, have had corporate documentation and procedures in place to assess the mental capacity of residents. These are regularly updated, eg when there are changes in legislation. Mrs Brown’s capacity was not formally assessed as it was not deemed that she lacked capacity, and the Mental Capacity Act states that capacity must always be assumed unless it is proved otherwise.”

    Source location

    Elsie-Brown-Response
    Page 1 · response
    Published 4 December 2015

    Open published response

  6. Norfolk

    AI-generated summary

    CHRISTOPHER WATSON · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Christopher Watson, who had become isolated after losing his job, was found dead in his home on 7 January 2015 after having been dead for some weeks. The concerns focused on Norfolk County Council Adult Social Care closing his file after sending a letter that Mr Watson might not receive, open or understand, and on the lack of direct contact to ensure he understood that help was available and to assess whether his capacity needed assessment. The inquest recorded that he died from exsanguination after cutting his own arm, with his intention not known.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to assess capacity where required

    Wider context from the report

    “(2) Mr Watson was clearly vulnerable from the description provided by the Police i.e. “painfully thin, unwashed and dishevelled”. Direct contact was not made with Mr Watson to ensure he understood help is available should he wish to take advantage of it. His capacity may have needed to have been assessed. ”

    Source location

    CHRISTOPHER WATSON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  7. Nottinghamshire

    AI-generated summary

    Cynthia Fretwell · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Cynthia Fretwell, aged 84, was admitted to hospital with abdominal pain, obstructive jaundice and suspected gallbladder inflammation, but was discharged after treatment with antibiotics. She later became unwell at home, was not admitted to hospital after GP contacts including a telephone consultation, and died that evening from peritonitis resulting from an infected gall bladder that had not responded to antibiotics. Concerns included telephone referral systems and responses, the threshold for telephone versus home consultations, assessment of mental capacity when refusing treatment or admission, and documentation of discussions.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to fully assess patients’ mental capacity when they refuse medical treatment or hospital admission

    Wider context from the report

    “(1) Telephone referrals and the lack of an effective system for conveying and responding to information between the caller and the doctor. Specifically, I had concerns about the following aspects: (a) The inability of reception staff to interrupt a GP during surgery for the purposes of alerting and informing the doctor of a change in the patient’s condition following a telephone referral. (b) Timely consultation and timely responses to telephone referrals from patients and their families. (c) The threshold for determining whether a telephone consultation is adequate or whether a home consultation should be undertaken. (2) A full assessment of the patient’s mental capacity in a situation where they are refusing medical treatment or admission to hospital. (3) Full and proper documentation of the discussions between the doctor and the patient/patient’s family in those circumstances. ”

    Source location

    Cynthia Fretwell · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Update and provide staff access to the Mental Capacity Act policy.

    Verbatim wording from the response

    “1. The Practice has updated its MENTAL CAPACITY ACT 2005 POLICY. This is saved on the ‘shared drive’ for all the staff to access it as necessary. See attached.”

    Source location

    2013-0366-Response-by-Hama-Medical-Centre
    Page 1 · response
    Published 16 December 2013

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Provide a Mental Capacity Act summary on the shared drive for staff reference.

    Verbatim wording from the response

    “2. A summary of the Mental capacity Act 2005 is also saved on the ‘shared drive’ for more detailed reference.”

    Source location

    2013-0366-Response-by-Hama-Medical-Centre
    Page 1 · response
    Published 16 December 2013

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Discuss the Mental Capacity Act during medical meetings to update staff on its principles, purposes and best-interests requirements.

    Verbatim wording from the response

    “4. We have discussed the Mental Capacity Act during our Medical Meetings so that we are all updated on it. Particular attention has been paid to sections relating to the Principles of the Act, Purposes of the Act and Best interests, as highlighted in the copy of summary of Mental Capacity Act attached.”

    Source location

    2013-0366-Response-by-Hama-Medical-Centre
    Page 1 · response
    Published 16 December 2013

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Continue staff Mental Capacity Act training through appropriate courses and e-learning.

    Verbatim wording from the response

    “Capacity Act and PREVENT. This event addressed the principles and application of the Mental Capacity Act, amongst other issues. They will continue to keep themselves updated by attending appropriate future courses. ████████ will be attending such course in the very near future. The Practice staff have attended a course to learn about Mental capacity Act in 2009 and will update themselves with e-learning this subject on ‘blue stream academy’.”

    Source location

    2013-0366-Response-by-Hama-Medical-Centre
    Page 3 · response
    Published 16 December 2013

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Conduct a full mental capacity assessment when patients refuse medical treatment or hospital admission, following the practice policy.

    Verbatim wording from the response

    “2. A full assessment of the patient’s mental capacity in a situation where they are refusing medical treatment or admission to hospital will be made in accordance with the guidelines in the Practice’s mental capacity policy attached.”

    Source location

    2013-0366-Response-by-Hama-Medical-Centre
    Page 3 · response
    Published 16 December 2013

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026